Laparoscopic evaluation following failure to achieve pregnancy after ovulation induction with clomiphene citrate

Objective: To assess the value of laparoscopic evaluation of the pelvis after failure to achieve pregnancy with clomiphene citrate-induced ovulation and to determine whether predictors for significant pelvic pathology can be isolated. Design: Retrospective study. Setting: Tertiary care academic medical center. Patient(s): Ninety-two patients failing to conceive after four ovulatory cycles with clomiphene citrate with a normal hysterosalpingogram who underwent laparoscopic evaluation of the pelvis. Intervention(s): Laparoscopy. Main Outcome Measure(s): Presence of pelvic pathology and predictors of pelvic disease. Result(s): Of the 92 patients studied, 32 patients (34.8%) had a "positive" laparoscopy (i.e., stages III and IV endometriosis, an endometrioma, pelvic adhesions, and/or tubal disease), 27 patients (29.3%) had stage I or II endometriosis, and 30 patients (32.6%) had a normal pelvis. The predictors for intrapelvic disease were a history of dyspareunia, no prior use of oral contraceptive pills, and no prior use of any form of contraception. Almost 40% of women with predictors had a "positive" laparoscopy, compared with only 12.5% of patients without predictors; however, the majority of patients (91.3%) had at least one predictor. Conclusion(s): More than one third of the patients failing to conceive after four ovulatory cycles of clomiphene citrate had significant intrapelvic pathology. Although predictors for intrapelvic disease were isolated, their high prevalence reduced their predictive value.